Why We Need Practice Standards

Author: Patricia Gaffney, Au.D. and John Coverstone, Au.D. 

Practice standards have existed in most professions for many decades, if not longer. It is important for a profession to define standard methodologies for services commonly provided. When providers perform tasks differently, it leads to chaos in a healthcare system: other healthcare providers have difficulty coordinating care, teamwork becomes difficult for support staff, and patients notice inconsistencies in outcomes. Taken further, payers become uncertain as to the efficacy of care and education of new professionals becomes increasingly more chaotic as the disparities multiple with successive generations. Finally, the healthcare system loses faith in the profession.

Standards reduce risk for providers by minimizing adverse events. They promote faith in a profession because patients and other providers know what to expect. They support education and help to codify routine tasks for payers and regulators. They do not restrict practice because we recognize that all patients are different, and providers must utilize an array of tools to meet their needs. For this reason, we have clinical guidelines. Clinical guidelines provide a framework for patient care that allows for individual differences and multiple pathways to achieve positive outcomes.

The profession of audiology has not had standards describing the tasks we perform in clinical practice. In 2012, the American Academy of Audiology published Standards for Practice in Audiology. While this was a needed document and described the full breadth of what an audiologist might do within our scope of practice, many felt we needed standards that include more detailed descriptions of what audiologists do in specific areas. As a result, Audiology Practice Standards Organization (APSO) was founded in 2017 to develop and maintain clinical standards in audiology.

Individual practice standards serve as a foundation for guidelines, accreditation, licensing and education. They describe what a typical provider does with a typical patient in each situation (such as a diagnostic hearing evaluation or a hearing aid fitting). Practice standards describe the minimum tasks considered acceptable by the profession. Practice guidelines, on the other hand, describe how those tasks are performed and often include variations for different populations and hierarchies of preferred methods.

APSO standards are developed, reviewed and edited by two groups of subject matter experts prior to release for public comment. All audiologists are invited to review and comment on the standards, with substantiating evidence solicited when possible. After final revisions by the development SMEs, each standard is also subject to review by an ethics panel and legal team before publication. Each standard is freely available to download on the APSO web site at www.audiologystandards.org, as is the standards creation process.

The first two published APSO clinic standards are below.    

Standard S1.1 [2020]
Adopted March 18, 2020

The profession of audiology is committed to providing auditory and vestibular care through ethical and evidence-based clinical practices that lead to optimal patient outcomes. Standard of practice documents outline basic services that audiologists are expected to include in the provision of quality healthcare. They reflect the values and priorities of the profession, providing direction for professional practice and a framework for the evaluation of practice. Standards of practice are prepared by subject matter experts, based on available evidence, peer-reviewed and subject to periodic updating.

  1. During intake, information to be collected as applicable from the patient and/or the patient’s family member/legal representative will include but is not limited to:
    1. Demographic and contact information
    2. Legal and financial documents (e.g., consent to treat, insurance, HIPAA, release of medical information, prior authorization, medical referral and/or medical order when required)
    3. Chief complaint, history of present illness, and current symptoms including functional impact of hearing or balance deficit
    4. Information related to medical and surgical history (including comorbidities), current medications, allergies, medical/specialist team members, and cognitive and developmental concerns
    5. Social history to include marital status, sexual orientation and gender identity, employment history, recreational history of alcohol, drug, and tobacco use and environmental factors such as noise exposure history (military, occupational and recreational)
    6. Screening for the red flags of ear disease2
    7. Tinnitus and falls risk including nature, onset and impact on patient's quality of life sufficient to develop a care plan which may include referral to an appropriate healthcare professional
    8. Audiologic history (e.g. previous hearing examinations, hearing amplification devices) as available
  2. The following should be considered:
    1. Questioning may be completed in written or oral format
    2. Information shall be provided to and collected from the patient and/or patient’s family member/legal representative using methods required for effective communication (e.g. written, oral, or signed language and appropriate level to ensure understanding) in accordance with clinic policies.
    3. Specialized questionnaires may be completed if relevant to appointment type (see standards for specific areas of evaluation)
    4. Questions shall be tailored to patient characteristics (e.g., age, cognitive function, reason for visit)
  3. Following collection of information, the audiologist shall determine plan for evaluation
  4. Intake information collection will continue throughout course of the initial appointment and subsequent visits. This should be updated at least annually.
Audiologists are encouraged to familiarize themselves with the measures outlined in MIPS available at https://audiologyquality.org/measures/

Red Flags-Warning of Ear Disease: https://www.entnet.org/resource/position-statement-red-flags- warning-of-ear-disease/

© 2020 Audiology Practice Standards Organization

Standard S2.1[2021]
Adopted May 2, 2021

The profession of audiology is committed to providing auditory and vestibular care through ethical and evidence-based clinical practices that lead to optimal patient outcomes. Standard of practice documents outline basic services that audiologists are expected to include in the provision of quality healthcare. They reflect the values and priorities of the profession, providing direction for professional practice and a framework for the evaluation of practice. Standards of practice are prepared by subject matter experts, based on available evidence, peer-reviewed and subject to periodic updating.
  1. The hearing aid selection and fitting process is based on a comprehensive, valid audiological assessment. Each step of the selection and fitting process and the rationale is documented, where appropriate. 1, 2, 3
  2. Patient communication is conducted in a clear, empathetic manner consistent with the patient's communication mode, comprehension, and their health literacy level. Patient-centered and family- centered care is provided. The patient is encouraged to include communication partners (e.g., family members, significant others, companions) throughout the selection, fitting, and follow-up process. 4, 5, 6, 7, 8
  3. A needs assessment is conducted in determining candidacy and in making individualized amplification recommendations. A needs assessment includes audiologic, physical, communication, listening, self- assessment, and other pertinent factors affecting patient outcomes. 9, 10
  4. Pre-fitting testing includes assessment of speech recognition in noise, unless clinically inappropriate, and frequency-specific loudness discomfort levels. Other validated measures of auditory and non- auditory abilities are considered, as appropriate for the individual patient. 11, 12, 13, 14, 15, 16, 17, 18, 19
  5. Fitting of bilateral hearing aids is the recommended protocol if the patient is a candidate for hearing aids in both ears and it is supported by the needs assessment. 20, 21, 22
  6. The hearing aid style and the ear coupling are chosen to be appropriate for the degree and configuration of the hearing loss. Style and coupling should reflect any physical limitations of the patient. Patient input regarding acceptable styles is taken into account. 23, 24, 25, 26, 27, 28, 29, 30, 31, 32
  7. The recommended hearing aids include signal processing and features that support the patient’s listening needs. They have the appropriate gain and output, including reserve gain, to meet frequency-specific fitting targets as defined by a validated prescriptive method. 23, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43
  8. Assistive technology and accessories are considered to facilitate accessibility to other devices and to satisfy the patient’s listening and communication needs. 23, 44, 45, 46, 47, 48
  9. An assessment of initial product quality is completed, using standard electroacoustic measures to verify either manufacturer or published specifications. 34, 49
  10. Hearing aids are fitted so that various input levels of speech result in verified ear canal output that meets the frequency-specific targets provided by a validated prescriptive method. The frequency- specific maximum power output is adjusted to optimize the patient’s residual dynamic range and ensure that the output does not exceed the patient’s loudness discomfort levels. 50, 51, 52, 53, 54, 55, 56, 57
  11. Following individualized verification of hearing aid gain and output, if the fitting is not acceptable to the patient, minor deviations in gain and output may be necessary. 58, 59
  12. Orientation is device- and patient-centered and includes use, care, and maintenance of the hearing aid(s) and accessories. 60, 61, 62, 63
  13. Counseling is conducted to ensure appropriate adjustment to amplification and to address other concerns regarding communication. Additional rehabilitative audiology is recommended if deemed appropriate. 64,65,66,67,68,69
  14. Hearing aid outcome measures are conducted. These may include validated self-assessment or communication inventories and aided speech recognition assessment. 70, 71
  15. Short- and long-term follow-up is conducted to ensure that post-fitting needs are addressed. This includes updated audiological assessment, hearing aid adjustments and routine maintenance as needed to ensure the devices are functioning properly and appropriately for the patient. 23, 33, 72, 73, 74, 75

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